Exam 2 (Ch 7, 13-19, 29, 33, 37-39) Practice Questions Flashcards
A nursing professor pulls a student aside to discuss documenting a patient’s blood pressure of 202/122 but not reporting this to the primary nurse. When discovered, the patient was transferred to the intensive care unit for treatment and monitoring. How does the faculty best explain to the student that their inaction reflects negligence?
A. “You did not re-assess your patient.”
B. “There was poor interprofessional communication with the health care team.”
C. You failed to act as a reasonably prudent nurse would under similar circumstances.”
D. “This action is consistent with a felony criminal action.”
C.
RATIONALE:
c. Negligence is defined as performing an action that the reasonably prudent nurse would not perform or failing to act as a reasonably prudent nurse would in similar circumstances. Negligence may be an act of omission or commission. Criminal law concerning state and federal criminal statutes includes murder, manslaughter, criminal negligence, theft, and illegal possession of drugs. Public law regulates relationships between people and the government. Private or civil law includes laws relating to contracts, ownership of property, and the practice of nursing, medicine, pharmacy, and dentistry.
Nursing students approaching graduation and licensure are required to read the state nurse practice act. Which topics in the law will they identity as guides to professional practice? Select all that apply.
A. Actions resulting in discipline
B. Clinical procedures
C. Medication administration
D. Scope of practice
E. Delegation policies
F. Medicare reimbursement
A,D
RATIONALE:
a, d. Each state has a nurse practice act that protects the public by broadly defining the legal scope of nursing practice. Practicing beyond those limits makes nurses vulnerable to charges of violating the state nurse practice act. Nurse practice acts also list the violations that can result in disciplinary actions against nurses. Clinical procedures are covered by the health care institutions themselves. Medication administration and delegation are topics covered by the board of nursing. Laws governing Medicare reimbursement are enacted through federal legislation.
A nurse on a surgical unit is concerned about a colleague’s possible substance use disorder. Which signs and symptoms could support the nurse’s suspicion? Select all that apply.
A. Exhibiting diminished alertness and somnolence while working
B. Attending multiple continuing education conferences
C. Offering to medicate coworkers’ patients for pain
D. Making incorrect narcotics counts and creating wastage
E. Leaving the unit frequently
A, C, D, E
RATIONALE:
a, c, d, e. Signs of substance use in nurses may include diminished alertness or somnolence, leaving the unit frequently, incorrect narcotic counts, wastage, offers to medicate colleagues’ patients, or changes in job performance, among others. Attending professional conferences is an example of a nurse who is fully engaged with their work.
A new graduate nurse tells the preceptor they want to obtain recognition in wound care, a specialty area of nursing. What credential will this nurse need to seek?
A. Accreditation
B. Licensure
C. Certification
D. Board approval
C
RATIONALE:
c. Certification is the process by which a person who has met certain criteria established by a nongovernmental association is granted recognition in a specified practice area. Nursing is one of the groups operating under state laws that promote the general welfare by determining minimum standards of education through accreditation of schools of nursing. Licensure is a legal document that permits a person to offer to the public skills and knowledge in a particular jurisdiction, where such practice would otherwise be unlawful without a license. State board of approval ensures that nurses have received the proper training to practice nursing.
The nurse reports to their manager that informed consent was not obtained from a patient for whom HIV testing was already performed. The nurse suggests which intentional tort may have been committed?
A. Assault
B. Battery
C. Invasion of privacy
D. False imprisonment
B
RATIONALE:
b. Assault is a threat or an attempt to make bodily contact with another person without that person’s consent. Battery is an assault that is carried out. Every person is granted freedom from bodily contact by another person unless consent is granted. The Fourth Amendment gives citizens the right of privacy and the right to be left alone; a nurse who disregards these rights is guilty of invasion of privacy. Unjustified retention or prevention of the movement of another person without proper consent can constitute false imprisonment.
A patient died during routine outpatient surgery, and the nurse was accused of having failed to monitor and interpret vital signs. Which fact must be established to prove them guilty of malpractice or negligence?
A. The surgeon testifies the nurse’s action was pure negligence, saying that the patient could have been saved.
B. This patient should not have died since they were healthy, physically active, and involved in the community.
C. The nurse intended to harm the patient and was willfully negligent, as evidenced by the tragic outcome.
D. The nurse had a duty to monitor the patient, and due to the nurse’s failure to perform this duty, the patient died.
D
RATIONALE:
d. Liability involves four elements that must be established to prove that malpractice or negligence has occurred: duty, breach of duty, causation, and damages. Duty refers to an obligation to use due care (what a reasonably prudent nurse would do) and is defined by the standard of care appropriate for the nurse–patient relationship. Breach of duty is the failure to meet the standard of care. Causation, the most difficult element of liability to prove, shows that the failure to meet the standard of care (breach) caused the injury. Damages are the actual harm or injury resulting to the patient.
An attorney representing a patient’s family who is suing for wrongful death calls the nurse to obtain a better understanding of the nurse’s actions. How will the nurse respond?
A. “I can’t talk with you; you will have to contact my attorney.”
B. “I will answer your questions, so you’ll understand how the situation occurred.
C. “I hope I won’t be blamed for the death because it was so busy that day.”
D. “First tell me why you are doing this to me. This could ruin my career!”
A
RATIONALE:
a. The nurse should not discuss the case with anyone at the facility (except the risk manager), with the plaintiff, with the plaintiff’s lawyer, with anyone testifying for the plaintiff, or with reporters. This is one of the cardinal rules for nurse defendants.
A nurse follows a prescription written by the health care provider to administer a medication to which the patient is allergic. How does the nurse interpret their liability for administering this medication?
A. The nurse is not responsible because they were following the provider’s orders.
B. The nurse is responsible because they administered the medication.
C. The health care provider is responsible because they ordered the drug.
D. The nurse, health care provider, and pharmacist bear responsibility for their actions.
D
RATIONALE:
d. Nurses are legally responsible for carrying out the orders of the health care provider in charge of a patient unless an order would lead a reasonable person to anticipate injury if it was carried out. If the nurse should have anticipated injury and did not, both the prescribing health care provider and the administering nurse are responsible for the harms to which they contributed.
A nurse answers a call light and finds the patient on the floor. After the health care provider examines the patient and finds no injury, the nurse returns the patient to bed and fills out an incident report. What statements are true about incident reports? Select all that apply.
A. They can be used as disciplinary action against staff members.
B. They can be used as a means of identifying risks.
C. They can be used for quality control.
D. They must be completed by the facility manager.
E. They make facts available in litigation cases.
F. They should be documented in the patient record.
B,C,E
RATIONALE:
b, c, e. Incident reports are used for quality improvement and should not be used for disciplinary action against staff members. They are a means of identifying risks and are filled out by the nurse responsible for the injured party. An incident report makes facts available in case litigation occurs; in some states, incident reports may be used in court as evidence. A health care provider completes the incident form with documentation of the medical examination of the patient, employee, or visitor with an actual or potential injury. Documentation in the patient record should not include the fact that an incident report was filed.
A nursing student is preparing to administer medications and asks the clinical instructor about legal liability in clinical practice. What is the most appropriate response?
A. “Students are not responsible for their acts of negligence resulting in patient injury.”
B. “Student nurses are held to the same standard of care that would be used to evaluate the actions of a registered nurse.”
C. “Hospitals are exempt from liability for student negligence if the student nurse is properly supervised by an instructor.”
D. “Most nursing programs carry group professional liability making student personal professional liability insurance unnecessary.”
B
RATIONALE:
b. Student nurses are held to the same standard of care that would be used to evaluate the actions of a registered nurse. Student nurses are responsible for their own acts of negligence if these result in patient injury. A hospital may also be held liable for the negligence of a student nurse enrolled in a hospital-controlled program because the student is considered an employee of the hospital. Nursing instructors may share responsibility for damages in the event of patient injury if an assignment called for clinical skills beyond a student’s competency or the instructor failed to provide reasonable and prudent clinical supervision. Most nursing programs require students to carry personal professional liability insurance.
The nurse manager reviews the medical record of a patient who has accused a nurse of negligence after requiring a “needless” admission to the intensive care unit postoperatively. Which entry in the electronic health record requires follow-up by the manager?
Exhibit: Electronic health record (EHR)
Nursing Notes: Postoperative follow-up
12:20 pm: patient still reporting incisional pain of 10/10, provider contacted, increased morphine from 1 mg to 2 mg every hour
2: 15 pm: dime-sized, dark red–brown blood stain on dressing; area circled
2:30 pm: patient reports incisional pain, 7/10, 2 mg morphine administered
2:45 pm: vital signs T 99.2°, P 120, RR 20, BP 84/48; will continue to monitor
A. Inappropriately recorded vital signs
B. Pain treated without appropriate assessment
C. Failure to follow up on tachycardia and hypotension
D. Lack of interpretation of vital signs and follow-up
D
RATIONALE:
d. Nurses are responsible for gathering assessment data including vital signs and interpreting them considering the patient’s condition and trends. The nurse did not document interventions from the health care provider for typical symptoms of shock, including tachycardia and hypotension.
A patient admitted through the emergency department for a severe infection is receiving intravenous (IV) antibiotics. The patient, who has been oriented, demands the nurse remove the IV because the patient is leaving now. What action will the nurse take?
A. Apply soft wrist restraints
B. Perform a neurologic assessment
C. Explain that after signing an “against medical order form,” the patient may leave
D. Call the patient’s family to encourage the patient to stay
C
RATIONALE:
c. A person cannot be legally forced to remain in a health facility, such as a hospital, if that person is of sound mind. The patient signs an “against medical orders” form when insisting on being discharged, to indicate not holding the facility responsible for harm from leaving. Applying soft wrist restraints when the patient has expressed wanting to leave constitutes battery, which includes willful, angry, and violent or negligent touching of another person’s body or clothes or anything attached to or held by that other person. The patient has been oriented, so another assessment is not indicated. The patient, not the family, has autonomy.
A nursing student is committed to providing thoughtful, person-centered care. Which nursing actions demonstrate this type of care? Select all that apply.
A. Assisting patients to select meals based on their cultural observances
B. Providing nursing care based on patients’ needs and preferences
C. Documenting nursing interventions in the electronic health record
D. Reviewing fingerstick blood glucose levels with the primary nurse
E. Listening to a patient’s concern for their ill significant other
A, B, E
RATIONALE:
a, b, e. The nursing process ensures that nurses are person centered rather than task centered. Attending to cultural preferences and needs and listening to a patient’s concerns are patient-centered actions. Documentation and communication with other members of the health care team are not specifically patient centered.
A patient who is receiving cancer chemotherapy tells the nurse, “The treatment for this cancer is worse than the disease itself. I’m stopping treatment.” Which nursing action best promotes a patient-centered, therapeutic relationship?
A. Determining if the patient database is adequate to address the problem
B. Considering whether to suggest a counseling session for the patient
C. Reassessing the patient and determining how to best support them
D. Identifying possible interventions and critiquing the merit of each option
C
RATIONALE:
c. Reassessing the patient allows the nurse and patient to clarify the patient’s goal(s) and develop interventions to best meet them. Once the problem is addressed, it is important for the nurse to judge the adequacy of the knowledge, identify potential problems, use helpful resources, and critique the decision.
The nursing philosophy in an acute care hospital includes a commitment to deliver thoughtful, person-centered care. Which description of the nursing process best supports this commitment?
A. Systematic
B. Interpersonal
C. Dynamic
D. Universally applicable in nursing situations
B
RATIONALE:
b. Interpersonal. All other options are characteristics of the nursing process but focus on the patient best illustrates the interpersonal dimension of the nursing process.
A staff nurse tells a new graduate nurse not to bother studying too hard, since most clinical reasoning becomes second nature and intuitive once they begin practicing. Which response by the student is appropriate?
A. Intuitive problem solving comes with years of practice and observation based on nursing knowledge and science.
B. For nursing to remain a science, nurses must continue to be vigilant about avoiding intuitive reasoning.
C. The emphasis on logical, scientific, evidence-based reasoning has held nursing back; we need intuitive, creative thinkers.
D. The nurse’s preference dictates whether they are logical, scientific thinkers or intuitive, creative thinkers.
A
RATIONALE:
a. When intuition is used alone, increased risks and fewer benefits may occur. Beginning nurses must use nursing knowledge and scientific problem solving as the basis of care; intuitive problem solving comes with years of practice and observation. If the beginning nurse has an intuition about a patient, that information should be discussed with the faculty member, preceptor, or supervisor. There is a place for intuitive reasoning in nursing, but it will augment, not replace logical, scientific reasoning. Critical thinking is contextual and changes depending on the circumstances, not on personal preference.
The nurse uses blended competencies when caring for patients in a rehabilitation facility. Which interventions reflect the use of cognitive skills? Select all that apply.
A. Monitoring for side effects of medications
B. Safely administering an injectable medication
C. Teaching a patient about diabetes and its management
D. Acting as witness by signing a surgical consent form
E. Helping a patient identify their progress in physical therapy
F. Comforting a patient who has received bad news
A,C
RATIONALE:
a, c. Using critical thinking to teach a patient about a disease process and management and monitoring for side effects of medications are cognitive competencies. Performing an injection correctly is a technical skill; witnessing/signing an informed consent form is a legal/ethical action, and comforting a patient is an interpersonal skill.
A nurse uses critical-thinking skills to develop the care plan for an older adult with dementia awaiting placement in a long-term care facility. Which statements describe characteristics of the critical thinking used by nurses engaged in clinical reasoning? Select all that apply.
A. Functions independently of nursing standards, ethics, and state practice acts
B. Based on the principles of the nursing process, problem solving, and the scientific method
C. Driven by patient, family, and community needs as well as nurses’ needs to give competent, efficient care
D. Avoids designs to compensate for problems created by human nature, such as medication errors
E. Constantly reevaluating, self-correcting, and striving for improvement
F. Focuses on the big picture rather than identifying the key problems, issues, and risks involved with patient care
B,C,E
RATIONALE:
b, c, e. Critical thinking applied to clinical reasoning and clinical judgment is guided by standards, policies and procedures, and ethics. When applying principles of nursing process, problem solving, and the scientific method, clinical reasoning identifies the key problems, issues, and risks. This is driven by patient, family, and community needs as well as nurses’ needs to give competent, efficient care. It also calls for strategies that make the most of human potential and compensate for problems created by human nature. It is constantly reevaluating, self-correcting, and striving to improve the quality and safety of health care systems (Alfaro-LeFevre, 2014).
A nurse is caring for a patient with type 2 diabetes who has an infected foot ulcer requiring dressing changes. Which nursing action best demonstrates the QSEN competency of patient-centered care?
A. Asking the patient if they would like their spouse to be present for a teaching session
B. Researching new procedures to care for foot ulcers when developing a care plan for this patient
C. Leading a grand rounds or unit-based discussion on complications of diabetes
D. Using the electronic medical record to review trends of the patient’s blood glucose levels
A
RATIONALE:
a. Patient-centered care commits to developing caring relationships based on mutual trust to communicate and deliver care based on patient preferences and values. Evidence-based practice integrates the best current evidence for safe practice with clinical expertise. Teamwork and collaboration shares patient information or opportunities for learning with others. Informatics manages patient information, mitigates error, and supports decision making using the electronic medical record and other databases.
The nursing assessment of a patient with a diagnosis of anorexia nervosa reveals the patient consumes a vegan diet of 700 calories daily and has lost 30 lb in 4 months. The nurse’s recommendation to meet with a nutritionist is the outcome of which process?
A. Clinical judgment
B. Nursing process
C. Clinical reasoning
D. Critical thinking
A
RATIONALE:
a. Clinical judgment is the outcome of critical thinking and clinical reasoning, using the nursing process as a framework. Clinical reasoning refers to ways of thinking about patient care issues including weighing and validating options (determining, preventing, and managing patient problems). Critical thinking includes reasoning both outside and inside of the clinical setting.
A nurse working in a long-term care facility reviews the electronic health records of patients who have fallen in the last month to determine if there is a common risk factor. Which QSEN competency is the nurse demonstrating?
A. Patient-centered care
B. Evidence-based practice
C. Teamwork and collaboration
D. Informatics
D
RATIONALE:
d. Informatics uses information and technology to communicate, manage knowledge, mitigate error, and support decision making. Thoughtful, patient-centered care emphasizes recognition of the patient or designee as the source of control and full partner in compassionate and coordinated care, based on respect for patients’ preferences, values, and needs. Evidence-based practice integrates the best current evidence with clinical expertise and patient and family preferences and values to deliver optimal health care. Teamwork and collaboration refer to effective functioning within nursing and interprofessional teams, fostering open communication, mutual respect, and shared decision making to achieve quality patient care.
A new graduate nurse phones the surgeon to report their patient is having severe incisional pain. The surgeon asks about vital signs and appearance of the wound, causing the nurse to return to the bedside for additional assessments. Upon reflection with the preceptor, which characteristic of the nursing process should the nurse have remembered?
A. Centric
B. Dynamic
C. Interpersonal
D. Systematic
D
RATIONALE:
d. The nursing process is systematic, iterative, and overlapping. By reporting an isolated symptom, the nurse has overlooked the benefit of systematic and inclusive assessment. While the nursing process is presented as an orderly progression of phases, there is a dynamic interaction and flow of phases into one another.
The nurse is formulating a care plan for a patient in a long-term care facility who has lost 12 lb in the last 2 months. To arrive at a patient-centered nursing judgment, what will the nurse do first?
A. Ensure the patient is receiving foods they like, including favorites.
B. Make sure the patient’s dentures are clean and inserted at mealtimes.
C. Assess the patient’s food intake and hydration over the last 1 to 3 days.
D. Request that the nursing assistant feed the client at mealtime.
C
RATIONALE:
c. The nurse uses the nursing process to arrive at a clinical judgment. After analyzing the assessment data, the nurse determines, through clinical reasoning, whether the related factors in the patient’s weight loss, such as dislike of menu options, lack of dentition, or inability to perform activities of daily living such as feeding, should be the focus of interventions.
When implementing a thoughtful, patient-centered care plan, which action does the nurse prioritize?
A. The patient’s loved ones are considered part of the team.
B. A caring relationship with mutual trust is established.
C. Measures for safety are visibly incorporated.
D. Transparent communication is observed.
C
RATIONALE:
c. Although developing a thoughtful, patient-centered approach is focused on caring and mutual trust, the nurse uses the nursing process and Maslow’s hierarchy of needs to prioritize care. Safety is a higher-level need than love and belonging, and therefore the priority.
An oncology nurse is analyzing a patient’s strengths and finds the patient is well educated, learns quickly, and is resilient. In which phase of the nursing process will the nurse use this information?
A. Diagnosing
B. Evaluating
C. Planning
D. Implementing
A
RATIONALE:
a. Assessing for strengths and weaknesses is the first step of the nursing process, which has been completed. Next, the nurse clusters cues and develops diagnoses that give rise to interventions. Evaluating the plan is followed by completing or modifying the plan.
A student nurse walks into a patient room, introduces themselves, and begins to complete a full head-to-toe assessment. The clinical faculty member enters the room, introduces themselves, and asks the student to step out of the room for a moment. The student meets the faculty member in the hallway and is asked to identify 15 cues or observations they noted during their initial contact with the patient and the patient’s environment. Although the student is unable to reach 15 observations, the faculty guides the student to recognize the linen on the floor, old dinner tray on the windowsill, empty water pitcher, twisted oxygen tubing, the patient’s pallor, and several other things requiring action. What is the value of engaging in this kind of activity with students in the clinical setting?
A. Developing situational awareness is important to risk prevention, timely implementation of interventions, and prioritizing actions
B. Managing cognitive load begins with systematically sorting mental images and immediately addressing pressing concerns
C. Nursing best practice requires that an environmental scan be completed and documented in the electronic health record (EHR)
D. Designing interventions that increase patient satisfaction is an essential focus for nurses when completing their initial assessments
A
RATIONALE:
a. The case represents a concrete example of how students develop situational awareness and how that awareness develops with experience. Cognitive load management occurs in many ways; the use of mental images may not facilitate cognitive load management. Although an environmental scan is important, it is generally not documented in the EHR. Patient satisfaction is not the priority when completing the initial assessment; rapport formation, solid assessments, and good patient outcomes are associated with patient satisfaction.
A nursing program uses Tanner’s Clinical Judgment Model, a research-based model that accounts for differences in the patient, environment, and individual student nurse. What makes Tanner’s reflection step unique?
A. The emphasis is on noticing, interpreting, and responding; reflection is less important.
B. Reflection occurs both in-action (in the moment) and on-action (after the situation).
C. Reflection occurs first in the model that is focused on rapid decision making and patient outcomes.
D. Reflection is the last step in a linear model and is designed to minimize bias in the student nurse.
B
RATIONALE:
b. Reflection drives the clinical judgment cycle and allows for the integration of new knowledge that will inform future situations. Reflection is as important in Tanner’s model as the other elements of noticing, interpreting, and responding. The focus of the model is the development of clinical judgment, rather than rapid decision making; as clinical judgment is developed, decision making improves and may lead to better patient outcomes. Tanner’s model is cyclic, not linear; although bias may be addressed as part of the development of clinical judgment, it is not the focus.
Nursing programs prepare students for safe clinical practice. As a student nurse, why is a basic understanding of NCSBN’s Clinical Judgment Measurement Model (CJMM) important? Select all that apply.
A. Successful completion of the NCLEX is required for professional licensure in the United States.
B. Nurse educators use the CJMM model and NCLEX test plans to develop exam questions.
C. Students should be intimately familiar with theoretical models of education to answer questions.
D. Appreciation of the core principles assists students in understanding the structure and intent of nursing exams.
E. There is overlap in the core components of clinical judgment models, measurement models, and the nursing process.
A,B,D,E
RATIONALE:
a, b, d, e. Nurses in the United States must pass NCLEX prior to being issued a license to practice as a professional nurse. To help students achieve this goal, nurse educators model course exams on the NCSBN’s NCLEX test plan in terms of content and style. Understanding the why (rationale for actions) is often helpful when students are engaged in studying, working to apply the information they have learned, and developing test-taking strategies. There is overlap between the models and processes identified as foundational to nursing education, which demonstrates the importance of fundamental concepts. A deep understanding of theoretical and philosophical models is not necessary for student nurses.
Nursing students and those studying other health sciences (medicine, pharmacy, physical therapy, etc.) are often engaged in competency-based education. What is the value of competency-based education?
A. It provides comprehensive skills checklists for students to check their progress and move on to other elements.
B. It allows for student individualization based on their unique experience and preferences.
C. It provides specific guidance on the expected level of performance that integrates knowledge, skills, abilities, and judgment.
D. Like most other education models, it is a high-level way of thinking that is not related to clinical judgment.
C
RATIONALE:
c. The definition of a competency included in the Nursing: Scope and Standards of Practice (ANA, 2021) identified includes knowledge, skills, abilities, and judgment. Competency-based education is more than a checklist and often requires repeated exposure to concepts for mastery in a variety of contexts. Although the delivery of education can flex to meet the needs of students, testing is standardized to address core competencies. Competency-based education is very direct and concrete; the development of competence requires clinical judgment.
The development of clinical judgment requires intentional focus and a willingness to grow and change both personally and professionally. How can a nursing student best foster the development of clinical judgment?
A. Engaging in learning that only appeals to their preferred learning style
B. Focusing on knowledge acquisition that is straightforward and clear
C. Developing a model for learning that integrates feedback and reflection
D. Focusing inward to develop emotional intelligence and communication skills
C
RATIONALE:
c. Each nursing student is in charge of their learning, including integrating feedback from exams, clinical experiences, simulations, and other assignments—reflecting on what has been learned and integrating new learning. Adaptability is key. Classroom and clinical learning presents information in myriad ways and in different settings. Students should learn what they can from each situation and adapt their studying style as needed. Nursing knowledge, like patient care, is rarely straightforward and clear. Picking up on cues, emphasizing the correct element, answering the question being asked, and maintaining a person-centered focus that is individualized and nuanced requires practice and time. Students must give themselves the space and grace needed to learn and apply information in various situations. There is a reciprocity in learning that requires and inward and outward combination. Engagement with others and the environment is essential for shaping thinking and development of clinical judgment.
A nursing student tells the clinical instructor that their patient is fine and has “no complaints.” Which question by the faculty coaches the student to provide evidence that supports their assessments?
A. “Could you tell me how you validated this?”
B. “Do you think your patient feels free to share their concerns?”
C. “That’s good to hear. Tell me about the care you provided.”
D. “Please reassess the patient; they were admitted with a serious problem.”
A
RATIONALE:
a. The instructor is reminding the student that all data must be validated. Questioning the use of the word “fine” allows the nurse to determine if this is a social and reflexive response, and there may be another need the nurse can meet. Concluding that the patient does not trust the student is premature and is based on an invalidated inference. Saying “That’s good to hear” and asking the student to describe the care provided is incorrect because it accepts the invalidated inference. Telling the student to reassess the patient because they were admitted with a serious problem is incorrect because it is possible that the condition is resolving.
A nursery nurse notifies the nurse practitioner (NP) that a newborn has signs of jaundice. The NP performs a brief skin assessment, then orders a blood test for bilirubin levels. Which type of assessment has the NP performed?
A. Comprehensive
B. Initial
C. Time-lapsed
D. Quick priority
D
RATIONALE:
d. A quick priority assessment (QPA) is a short, focused assessment to obtain the most important information first. A comprehensive initial assessment is performed shortly after admission. The time-lapsed assessment is used to compare a patient’s current status to baseline data obtained earlier.
The nurse is admitting a pregnant patient to the hospital for treatment of pregnancy-induced hypertension. The patient asks the nurse, “Why are you doing a history and physical exam when the doctor just did one?” What statements will the nurse use to explain the primary purpose of the nursing assessment? Select all that apply.
A. “The nursing assessment will allow us to plan and deliver individualized, holistic nursing care that draws on your strengths.”
B. “It’s hospital policy. I know we ask a lot of questions, but I will try to make this quick.”
C. “As a nursing student, I need to develop assessment skills about your health status and need for nursing care.”
D. “This validates that your responses with the medical exam are consistent and that all our data are accurate.”
E. “I will check your health status and see what kind of nursing care you may need.”
F. “This is to determine the necessity for referring your nursing care needs to a health care provider.”
A, E, F
RATIONALE:
a, e, f. Medical assessments target data pointing to pathologic conditions, whereas nursing assessments focus on the patient’s responses to actual and potential health problems. The initial comprehensive nursing assessment results in baseline data that enable the nurse to make a judgment about a patient’s health status, the ability to manage their own health care and the need for nursing. It also helps nurses plan and deliver individualized, holistic nursing care that draws on the patient’s strengths and promotes optimum functioning, independence, and well-being, and enables the nurse to refer the finding(s) to the health care provider or collaborate with other health care professionals where indicated. Citing hospital policy or student learning is a secondary reason, and although it may be true that a nurse may need to develop assessment skills, it is not the main reason for a nursing history and assessment. The assessment augments the medical examination but is not performed to check its accuracy.
During shift report, a nurse says that a patient has no integumentary changes or skin care needs. During assessment, the nurse observes reddened areas over bony prominences. What action will the nurse take?
A. Correct the initial assessment form
B. Redo the initial assessment and document current findings
C. Conduct and document an emergency assessment
D. Perform and document a focused assessment of skin integrity
D
RATIONALE:
d. Perform a focused skin assessment for the new problem, documenting the current date. The initial assessment was entered in the permanent health record, correct at the time, and cannot legally be rewritten. An emergency assessment is performed for a life-threatening problem.
A nursing student is performing a nursing history for the first time. The student asks the primary nurse how anyone learns all the questions needed to get complete baseline data. What would be the nurse’s best reply?
A. “There’s a lot to learn at first, but once it becomes part of you, you just ask the same questions over and over in each situation until you can do it in your sleep!”
B. “You make the basic questions a part of you and apply critical thinking to modify them, to help you plan quality care.”
C. “It is really hard to learn how to do this well, as each history is different. I often feel like I’m starting fresh with each new patient.”
D. “Don’t worry about learning all of the questions to ask. Every facility has its own assessment form you must use.”
B
RATIONALE:
b. Once a nurse learns what constitutes the minimum data set, it can be adapted to each patient situation. It is not true that each assessment is the same even when using the same minimum data set, nor is it true that each assessment is uniquely different. Nurses committed to thoughtful, person-centered practice individualize their questions to each patient and situation. When using a standard facility assessment tool the nurse must still use critical thinking to individualize questions or follow up on patient information.
The nurse collects subjective and objective data during a patient assessment. When documenting, which data points will the nurse include as subjective data? Select all that apply.
A. Feeling nauseated
B. Edematous ankles
C. Feeling anxious about test results
D. Report of left arm tingling
E. Pain rated 7 on a scale of 1 to 10
F. Oral temperature of 101°F
A, C, D, E
RATIONALE:
a, c, d, e. Subjective data are information perceived only by the affected person. Examples of subjective data are feeling nauseated, anxious, tingling, and experiencing pain. Objective data are observable and measurable data that can be seen, heard, felt, or measured by someone other than the person experiencing them. Examples of objective data are fever or 101°F or edema.
When a nurse enters the patient’s room to begin a nursing history, the nurse notes the patient’s spouse is present. After greeting them, what action will the nurse take?
A. Thank the spouse for being present
B. Ask the spouse if they want to remain
C. Ask the spouse to leave
D. Ask the patient if they would like the spouse to stay
D
RATIONALE:
d. The patient has the right to privacy and to determine who will be present during the nursing history and exam. The nurse does not presume the patient’s preference, as the decision belongs to the patient, not their spouse.
A nurse is performing an initial comprehensive assessment of a patient admitted to a long-term care facility. The nurse begins the assessment by asking the patient, “How would you describe your health status and well-being?” and, “What do you do to keep yourself healthy?” These questions reflect what model for organizing data?
A. Maslow’s hierarchy of needs
B. Gordon’s functional health patterns
C. Human response patterns
D. Body system model
B
RATIONALE:
b. Gordon’s functional health patterns begin with the patient’s perception of health and well-being and progress to data about nutritional–metabolic patterns, elimination patterns, activity, sleep/rest, self-perception, role relationship, sexuality, coping, and values/beliefs. Maslow’s model is based on the human needs hierarchy. Human responses include exchanging, communicating, relating, valuing, choosing, moving, perceiving, knowing, and feeling. The body system model is based on the functioning of the major body systems.
The nurse notes a temperature of 102°F in a patient scheduled for surgery in 30 minutes. As the patient has been afebrile and asymptomatic until now, what action will the nurse take next?
A. Inform the charge nurse
B. Notify the surgeon
C. Reassess the temperature
D. Document the finding in the electronic health record
C
RATIONALE:
c. The nurse validates assessment findings that deviate from normal patterns or are unsupported by other data. Should the initial measurement be in error, it would have been premature to notify the charge nurse or the surgeon. The nurse must be sure that all data are accurate prior to documenting and reporting. If there is a question about accuracy, the data should be validated before documenting.
During a change-of-shift report, a nurse receives information that a patient admitted with hypertensive emergency has prescriptions for antihypertensive medications given at 8 AM and due at 8 PM. During the 8:00 PM assessment, the patient’s blood pressure is 90/60, and they report slight dizziness upon standing. After returning the patient to bed, what action will the nurse take?
Exhibit: Electronic health record, vital signs
8:00 AM 182/100
12:00 PM 168/98
4:00 PM 160/88
A. Record the BP in the electronic health record
B. Notify the health care provider
C. Administer the 8:00 PM medications
D. Place the patient flat in bed
B
RATIONALE:
b. When assessment findings reveal a critical change in the patient’s health status, the nurse reports the data (verbally) immediately. The nurse verifies the BP and notifies the health care provider, who may prescribe withholding blood pressure medications, assessment of orthostatic vital signs, among other actions. There is no indication the patient needs to lie flat at this time.
During an assessment, the nurse on a neurologic unit finds the patient confused to time and place but able to state their name. How will the nurse best record this in the electronic health record?
A. Is more confused than yesterday
B. States the year is 1975 and they are at a wedding
C. Disoriented to person, time, and place
D. Patient’s speech is garbled
B
RATIONALE:
b. While the patient is confused, it is most important to clearly describe the behavior for comparison to past and future behavior. Citing the actual year and events (orientation to time and place) provides context; “patient confused” is open to misinterpretation. Garbled speech refers to speech that is unclear; the patient may have difficulty with pronunciation or speak slowly, which is not necessarily reflective of confusion.
A nursing student is assigned to the emergency department (ED) to shadow the triage nurse. What activity will the student expect to perform?
A. Acute and emergency interventions
B. Daily care and assistance with ADLs
C. Assessment and prioritization of care
D. Care planning for return to home
C
RATIONALE:
c. The triage nurse screens patients to determine the extent and severity of their problems. They use highly specialized nursing knowledge and clinical reasoning and make clinical judgments to prioritize who must be seen immediately and who can wait. Patients in the ED are stabilized and transferred to the appropriate level of care; therefore, daily care, assistance with ADLs, planning for return home, and providing interventions are not part of the triage nurse’s role. Should the patient need emergency interventions, the triage nurse moves the patient to the appropriate area in the ED.
The nurse is assigned to care for a group of patients. Which patient will the nurse assess first?
A. Postoperative patient reporting pain 4/10
B. Individual with pneumonia whose WBCs are now 7,000
C. Adolescent with a burn to the face who is going home tomorrow
D. Patient’s pulse oximetry reading 89%, as reported by AP
D
RATIONALE:
d. The nurse uses Maslow’s hierarchy of needs to prioritize assessing the patient with hypoxemia, manifested by a pulse oximetry reading of 89%. The postoperative patient is reporting moderate pain; the patient with pneumonia has normal WBCs; the adolescent patient with a burn to the face is stable for discharge. These patients can be seen as soon as possible.
The nurse assessing a patient plans to use the OLD CARTS mnemonic to organize their questions. What questions will the nurse include in the assessment? Select all that apply.
A. “Can you tell me when the problem began”?
B. “Where were you sitting when this started?”
C. “Have your symptoms stopped and/or started again?”
D. “Would you describe your pain as sharp, dull or burning?”
E. “What do you believe has caused this problem?”
A,C,D
RATIONALE:
a, c, d. The OLD CARTS mnemonic refers to Onset: “When did your symptom(s) begin”?. Location: “Where is the symptom”?. Duration: “Is it episodic or constant?” or “How long does it last”?. Characteristics: “How would you describe it?.” Alleviating and Aggravating factors: “What makes it better or worse?.” Relieving factors: “What makes it better?.” Treatments: “Have you tried anything to make it better?.” Severity: “On a scale of 1–10, with 1 being the lower number, how serious is the symptom?.”
A nurse in the emergency department is assessing a young adult who has cognitive disability and is reporting severe abdominal pain. The patient is accompanied by the director of the group home where they live. When collecting data from this patient, which action reflects best practice?
A. Ask the assessment questions of the director.
B. Wait for the young adult’s parents to arrive before performing the assessment.
C. Ask the young adult questions and validate with the adult present.
D. Perform the physical assessment, then the intake interview when the family arrives.
C
RATIONALE:
c. Children and people with decreased mental capacity or impaired verbal ability should be encouraged to respond to interview questions as best as they can. This communicates support of the patient’s autonomy, expression of their needs, and respect for their abilities. The information is then validated with family members or guardians as appropriate.
A nursing student on the surgical unit is assigned to perform a review of systems using the head-to-toe format on a patient admitted for a fractured femur. Using this format, what system will the student assess first?
A. Genitourinary
B. Neurologic
C. Respiratory
D. Musculoskeletal
B
RATIONALE:
b. The nursing physical assessment involves the examination of all body systems in a systematic manner, commonly using a head-to-toe format called the review of systems (ROS). This assessment begins at the top of the body with the neurologic system and moves downward.
A registered nurse is formulating nursing diagnoses for a patient with multiple fractures. Which actions does the nurse take during this step of the nursing process? Select all that apply.
A. Conducting a nursing interview to collect patient data
B. Analyzing data collected in the nursing assessment
C. Developing a care plan for the patient
D. Pointing out the patient’s strengths
E. Assessing the patient’s mental status
F. Identifying community resources to help the family cope
B,D,F
RATIONALE:
b, d, f. Diagnosing includes identifying actual or potential health problems for individuals, groups, or communities; identifying factors that contribute to or cause health problems (etiologies); and identifying resources or strengths the individual, group, or community can draw on to prevent or resolve problems. The nurse assesses and collects patient data in the assessment step and develops the care plan during the planning phase of the nursing process.
A nurse is caring for a patient who presents with dyspnea, tachypnea, productive cough, fever, and low oxygen saturation. When developing the nursing care plan, which health problems might the nurse identify for this patient? Select all that apply.
A. Bronchial pneumonia
B. Impaired gas exchange
C. Impaired Respiratory System Function
D. Altered breathing pattern
E. Impaired Thermoregulation
B,C,D,E
RATIONALE:
b, c, d, e. Nursing diagnoses are actual or potential health problems that can be prevented or resolved by independent or interdependent nursing interventions. These include Impaired gas exchange, supported by low oxygen saturation; Impaired Respiratory System Function; Altered breathing pattern, supported by dyspnea and tachypnea; and Impaired Thermoregulation. Pneumonia is a medical diagnosis.
After assessing a patient recovering from a stroke in a rehabilitation facility, the nurse’s initial analysis suggests a potential health problem of situational low self-esteem. How will the nurse record the problem when they believe more data are needed?
A. No problem
B. Possible problem
C. Actual nursing diagnosis
D. Clinical problem other than nursing
B
RATIONALE:
b. When a possible problem exists, the nurse must collect more data to confirm or disprove the suspected problem. The conclusion, “no problem,” indicates no nursing response is required. When an actual problem is identified, the nurse continues using the steps of the nursing process by planning, goal setting, implementing, and evaluating care to resolve the problem. A clinical problem other than nursing diagnosis requires a collaborative approach with the appropriate health care professionals.
When caring for a patient who sustained a spinal cord injury, the nurse formulates the health problem:
Impaired Tissue Integrity
Etiology: sensory and motor deficit
Signs and symptoms: difficulty turning, reddened areas on heels and sacrum
Which phrase gives direction to the underlying cause of the problem?
A. Impaired Tissue Integrity
B. Sensory and motor deficit
C. Signs and symptoms
D. Reddened areas of skin on the heels and back
B
RATIONALE:
b. The etiology, sensory and motor deficits, identifies the contributing or causative factors of the problem. The problem, “Impaired Tissue Integrity: Impaired Skin Integrity,” states the undesirable health condition, life processes, or human response. The phrase, “Signs and symptoms: non-blanchable reddened areas on heels and back,” contains the defining characteristics of the problem.
A nurse is caring for a patient who refuses to look at or care for a new colostomy. The patient states, “I don’t care what I look like anymore. I’m not washing up, let alone touching or changing this bag!” The nurse formulates the health problem: Difficulty Coping: Impaired Acceptance of Health Status, reflecting which type of health problem?
A. Collaborative
B. Interdisciplinary
C. Medical
D. Nursing
D
RATIONALE:
d. Difficulty Coping: Impaired Acceptance of Health Status is a nursing problem, falling within the scope of independent nursing practice. Collaborative and interdisciplinary problems are resolved through a teamwork approach with other health care professionals. A medical problem is a traumatic or disease condition validated by medical diagnostic studies.
A nursing student obtains a blood pressure reading of 148/100. To determine the significance of this reading, what action will the nurse take first?
A. Comparing this reading to standards and trends in the medical record
B. Checking the taxonomy of nursing diagnoses for a pertinent label
C. Checking a medical text for the signs and symptoms of high blood pressure
D. Consulting with experienced nurse colleagues
A
RATIONALE:
a. A standard, or a norm, is a generally accepted rule, measure, pattern, or model to which data can be compared within the same class or category. When interpreting the significance of a patient’s blood pressure reading, the nurse uses normative values for the patient’s age group, race, and illness category and compares these to the patient’s recent results. Identifying the reason for deviation from a norm gives direction to the etiology of a health problem (e.g., insufficient knowledge, nutrition, stress, and coping, or other).
A nursing student tells the primary nurse that their patient has not had a bowel movement for 2 days and suggests adding the health problem “Constipation” to the care plan. How would the nurse best respond?
A. “Did you assess the patient’s usual bowel patterns and appearance of the last stool?”
B. “This early diagnosis will help us manage the problem before it becomes severe.”
C. “Have you determined if this is an actual or a possible diagnosis?”
D. “This condition requires a medical diagnosis.”
A
RATIONALE:
a. Patient health problems are derived from clusters of related data and patterns, rather than a single cue. The nurse determines if this is the patient’s usual bowel pattern, or whether an underlying reason exists for the lack of a bowel movement. Constipation is a health problem the nurse can resolve with independent or interdependent nursing actions.
A nurse is caring for a patient who has been admitted the second time this month for hypertensive emergency. The care plan contains the health problem:
Nonadherence
Etiology: lack of knowledge of purpose of medications
Signs and symptoms: BP, 220/112; readmitted for hypertensive crisis after 2 weeks
When meeting the patient, which action will the nurse take first?
A. Teach the patient that nonadherence may lead to stroke and heart disease
B. Discuss what will motivate the patient to adhere to the medication regimen
C. Explain that these medications are essential to their health and illness prevention
D. Determine the patient’s knowledge about the medications and their side effects
D
RATIONALE:
d. Using the nursing process, the nurse first assesses the patient’s knowledge base; this also confirms the accuracy of the problem statement. Problem statements with unclear etiologies may lead to inappropriate, erroneous, or unhelpful interventions. If the patient has difficulty affording medications or is experiencing side effects, a collaborative problem can be resolved jointly by the nurse, social worker, and health care provider.
A nurse in the psychiatric clinic is developing a problem list for a patient. What statement best reflects a correctly written, two-part problem?
A. Difficulty Coping: Impaired Family Coping
Etiology: inability to maintain marriage
B. Difficulty Coping: Impaired Acceptance of Health Status
Etiology: anger management issues
C. Impaired Cognition: Distorted Thought Process
Etiology: psychosis as evidence by hallucinations
D. Impaired Cognition: Decisional Conflict
Etiology: placement of parent in a long-term care facility
D
RATIONALE:
d. A correctly written two-part problem statement includes the health problem and the etiology or cause. The problem statement and etiology should avoid signs and symptoms, medical diagnoses, and something that cannot be changed. Inability to maintain marriage and anger issues do not identify the underlying cause of the problem and may themselves reflect the true problem. Psychosis is a medical diagnosis, which should not be used to support a patient problem.
A nurse is developing a problem list for a care plan. Which reflects a correctly written three-part problem statement? Select all that apply.
A. Difficulty Coping: Impaired Family Coping:
Etiology: lack of knowledge about tube feeding
Signs and symptoms: child needing tube feeding discharged to home
B. Impaired Nutritional Status: Impaired Nutritional Intake
Etiology: striving for perfect weight, wishes to excel in gymnastics
Signs and symptoms: 20-lb weight loss in 1 month
C. Need to learn how to care for child on ventilator at home
Etiology: discharge of child after 3-month hospital stay
Signs and symptoms: repeated comments, “I know I’ll harm her because I’m not a nurse.” and “I can’t do medical things.”
D. Impaired Spiritual Status
Etiology: inability to accept diagnosis of terminal illness
Signs and symptoms: comments such as, “I don’t deserve this”; “I’ve tried to live my life well”; and “How could God make me suffer this way?”
E. Impaired Tissue Integrity: Impaired Skin Integrity
Etiology: failure of home health aides to turn patient every 2 hours
Signs and symptoms: stage 3 pressure wound on sacrum.
D
RATIONALE:
d. Correctly written problem statements contain a problem the nurse can treat with independent or interdependent interventions, a clearly stated etiology or cause of the problem, and supporting signs and symptoms. Option (a) may be more easily resolved with the problem statement, knowledge deficiency. Option (a) further states the tube feeding is the underlying cause of the problem; it is a factor that cannot be changed. Option (c) is written in terms of needs and not an unhealthy response. Option (e), while written in three parts, places blame or implies negligence, which is legally inadvisable and should be avoided. A clear etiology is not stated in option (e), impeding direction for appropriate interventions or outcomes.
A nurse is caring for a patient recovering from a stroke that paralyzed the dominant arm. The nursing assistant reports that the patient was unable to bathe, comb their hair, or brush their teeth. Which health problem should the nurse add to the care plan?
A. Lack of motivation to complete self-care activities
B. Risk for: Activities of Daily Living Deficit
C. ADL deficit: impaired dressing and grooming
D. Impaired musculoskeletal system function: paralysis
C
RATIONALE:
c. The nurse clusters the data that demonstrates the patient’s (actual) inability to perform bathing and grooming. For that reason, a “potential problem” or “risk” is not appropriate. There is no evidence the patient lacks motivation, and paralysis is not a problem the nurse can resolve.
A nurse is caring for a patient who had abdominal surgery yesterday. The nurse observes the patient guarding the area with hands and a pillow, refusing to move, and grimacing. What information does the nurse use to formulate the health problem statement?
A. Symptoms
B. Diagnostic statement
C. Etiology
D. Cue
D
RATIONALE:
d. A cue denotes significant data or “red flags,” that, when occurring in a pattern or cluster, point to the existence of a health problem.
When developing the admission care plan for a patient with multiple sclerosis and quadriplegia, the nurse formulates the patient problem: Impaired Tissue Integrity: Impaired Skin Integrity. What action will the nurse take next?
A. Elevate the patient’s heels off the bed using a pillow
B. Develop a goal that the patient will consume protein at each meal
C. Delegate assessment of the skin on the patient’s back to the AP
D. Teach the patient to turn themselves in bed every hour
B
RATIONALE:
b. After the health problem is developed, the nurse begins the planning phase of the nursing process, which includes goal development. Elevating the heels and teaching the patient to turn are interventions used during the implementation phase. Delegating an assessment to the AP is an incorrect activity; assessment falls within the role and scope of practice of the professional nurse. In addition, the nurse must perform the skin assessment to develop the problem and plan care.
A nurse has performed an admission assessment on a patient. What step does the nurse perform after clustering the data?
A. Developing interventions
B. Nursing judgments
C. Diagnosing and analyzing
D. Concept mapping
C
RATIONALE:
c. After clustering the data, the nurse analyzes the data and formulates a nursing diagnosis. Interventions are based on and developed after goal setting. Nursing judgments are outcomes based on critical thinking and clinical reasoning. A concept map is a diagram or pictorial representation of the (student) nurse’s understanding of the interactions and relationships of the patient’s problems and plan of care.
A nurse notices a patient crying after meeting with the health care provider. Prior to formulating a health problem of difficulty coping, the nurse seeks to further support the problem by gathering which data?
A. Abnormal vital signs
B. Underlying cause of the tears
C. Admitting diagnosis
D. Patient’s support system
B
RATIONALE:
b. The nurse continues gathering data, determining the presence of a problem of grief, impaired coping, etc., by determining the underlying cause of the tears. If the patient received news that a biopsy was free from cancer, perhaps no problem exists. If the patient was told they have a terminal illness, the nurse can continue to gather data and plan to support the patient’s physical and emotional needs.
A nurse is planning care for a patient admitted to the hospital for treatment of a drug overdose. What actions will the nurse take during the outcome identification and planning step of the nursing process? Select all that apply.
A. Formulating nursing diagnoses
B. Identifying expected patient outcomes
C. Selecting evidence-based nursing interventions
D. Explaining the nursing care plan to the patient
E. Assessing the patient’s mental status
F. Evaluating the patient’s outcome achievement
B,C,D
RATIONALE:
b, c, d. During the outcome identification and planning step of the nursing process, the nurse, patient, and family collaborate to establish priorities and identify and write expected patient outcomes. The nurse selects evidence-based nursing interventions, and communicates the care plan. These steps may overlap; however, formulating and validating nursing diagnoses are typically performed during the diagnosing step. Assessing mental status is part of the assessment step, and evaluating patient outcomes occurs during the evaluation step of the nursing process.
Nurses on a hospital unit work to improve staff communication, as outlined in The Joint Commission’s National Patient Safety Goals. What process will best provide for continuity of the plan of care?
A. Checking two patient identifiers, such as name and date of birth, prior to administering medications
B. Ensuring two nurses check doses of high-risk medications such as anticoagulants or insulin
C. Giving handoff report in the patients’ rooms to update the next nurse on the plan of care
D. Obtain a patient sitter for a confused individual who has fallen trying to get out of bed
C
RATIONALE:
c. One of the published standards and requirements for accreditation and certification required by The Joint Commission is to “improve staff communication.” Communicating the plan of care with the patient and oncoming and off going nurses meets this goal. Using patient identifiers relates to the goal of safely identifying patients, checking high-risk medications relates to decreasing medication errors, and obtaining a patient sitter relates to general safety and fall reduction.
A nurse on a mother–baby unit engages in informal planning while providing ongoing nursing care. What actions are included in this type of planning? Select all that apply.
A. Sitting down with a patient and prioritizing existing diagnoses
B. Assessing a woman for postpartum depression during patient education
C. Planning interventions for a patient with a risk for bleeding
D. Taking time to speak with a new mother who just received bad news
E. Reassessing a patient who reports their pain medication is not working
F. Coordinating home care for a patient being discharged later today
B, D,E
RATIONALE:
b, d, e. Informal planning is a link between identifying a patient’s strength or problem and providing an appropriate nursing response, often while rearranging priorities. Examples of this include the nurse integrating assessment for postpartum depression during patient care, providing a therapeutic presence for a patient who received bad news, or reassessing a patient for pain during rounding. Formal planning involves prioritizing diagnoses, formally planning interventions, and coordinating the home care of a patient being discharged.
To plan the day, a nurse is prioritizing patient diagnoses according to Maslow’s hierarchy of human needs. What patient problem will the nurse address first?
A. Altered body image perception
B. Impaired gas exchange
C. Grief
D. Situational low self-esteem
B
RATIONALE:
b. Because basic needs must be met before a person can focus on higher ones, Maslow’s hierarchy of needs sets the priorities as: (1) physiologic needs, (2) safety needs, (3) love and belonging needs, (4) self-esteem needs, and (5) self-actualization needs. Answer (b) is an example of a physiologic need, (a and d) are examples of a self-esteem need, and (c) is an example of a love and belonging need.
Nurses on an oncology unit plan to adopt use of critical pathways for patients receiving chemotherapy. What positive features of this system will the nurses anticipate? Select all that apply.
A. Accessible computerized practice standards, easily individualized for patients
B. Binary decision tree for stepwise assessment and intervention
C. Ability to measures the cause-and-effect relationship between pathway and patient outcomes
D. Research-based practice recommendations that may or may not have been tested in clinical practice
E. Preprinted provider prescriptions, using standards validated through research, to streamline care
F. Outcomes with suggested time frames for achievement
A,C,F
RATIONALE:
a, c, f. Critical pathways represent a sequential, interdisciplinary, minimal practice standard for a specific patient population, that provide flexibility to alter care to meet individualized patient needs. They provide the ability to measure a cause-and-effect relationship between pathway and patient outcomes. An algorithm is a binary decision tree that guides stepwise assessment and intervention with intense specificity and no provider flexibility. Guidelines are broad, research-based practice recommendations that may or may not have been tested in clinical practice, and an order set is a preprinted provider order used to expedite the order process after a practice standard has been validated through analytical research.
A nurse is developing outcomes in the affective domain for a patient with a foot ulcer related to diabetes. Which outcome best addresses this domain?
A. Within 1 day after teaching, the patient will list three benefits of continuing to apply moist compresses to foot ulcer after discharge.
B. By 6/12/25, the patient will correctly demonstrate application of wet-to-dry dressing on the foot ulcer.
C. By 6/19/25, the patient’s pressure ulcer will decrease in size from 3 to 2.5 inches.
D. By 6/12/25, the patient will verbalize they value their health sufficiently to control diabetes and prevent recurrence of diabetic ulcers.
D
RATIONALE:
d. Affective outcomes describe changes in patient values, beliefs, and attitudes. Cognitive outcomes (a) describe increases in patient knowledge or intellectual behaviors; psychomotor outcomes (b) describe the patient’s achievement of new skills; and (c) is an outcome describing a physical change in the patient.
A nurse is developing a clinical outcome for a patient who is an avid runner and is recovering from a stroke resulting in right-sided paresis. Which clinical outcome is most appropriate to include in the care plan?
A. After receiving 3 weeks of physical therapy, patient will demonstrate improved movement on the right side of her body.
B. By 8/15/25, patient will be able to use right arm to dress, comb hair, and feed herself.
C. Following physical therapy, patient will begin to gradually participate in walking/running events.
D. By 8/15/25, patient will verbalize feeling sufficiently prepared to participate in running events.
B
RATIONALE:
b. Clinical outcomes describe the expected status of health issues at certain points in time, after treatment is complete. Functional outcomes (b) describe the person’s ability to function in relation to the desired usual activities. Quality-of-life outcomes (c) focus on key factors that affect someone’s ability to enjoy life and achieve personal goals. Affective outcomes (d) describe changes in patient values, beliefs, and attitudes.
A nurse is caring for a patient with dehydration who has a prescription to encourage oral fluids. Which outcome statement will best direct nursing interventions?
A. Offer patient 60 mL of fluid every 2 hours while awake.
B. During the next 24-hour period, patient’s fluid intake will total at least 2,000 mL.
C. Teach the patient the importance of drinking enough fluids to prevent dehydration by 1/15/25.
D. At the next visit on 12/23/24, patient will know to drink at least 3 L of water per day.
B
RATIONALE:
b. The outcomes in (a) and (c) make the error of expressing the patient goal as a nursing intervention. Incorrect: “Offer the patient 60 mL fluid every 2 hours while awake.” Correct: “The patient will drink 60 mL fluid every 2 hours while awake, beginning 1/3/25.” The outcome in (d) makes the error of using verbs that are not observable and measurable. Verbs to be avoided when writing outcomes include “know,” “understand,” “learn,” and “become aware.”b. The outcomes in (a) and (c) make the error of expressing the patient goal as a nursing intervention. Incorrect: “Offer the patient 60 mL fluid every 2 hours while awake.” Correct: “The patient will drink 60 mL fluid every 2 hours while awake, beginning 1/3/25.” The outcome in (d) makes the error of using verbs that are not observable and measurable. Verbs to be avoided when writing outcomes include “know,” “understand,” “learn,” and “become aware.”
A nurse is writing outcomes for a patient admitted with a cardiac condition causing fluid overload and edema. Which reflects an appropriately worded outcome?
A. Offer to elevate the patient’s legs on a stool while out of bed
B. Patient will restrict fluids to 1,500 mL per 24-hour period
C. Monitor the patient’s intake and output
D. Weigh the patient each morning prior to breakfast
B
RATIONALE:
b. The terms goal, objective, and outcome are often used interchangeably to refer to the expected conclusion to the patient’s health problem or expectation. Nurses use the phrase expected outcomes to refer to the more specific, observable, and measurable changes. Options a, c, and d are stated as interventions, rather than outcomes.
